To Health Insurance Consumers:
TO ASK YOUR HMO
"THE TEN COMMANDMENTS for HMOs"
Prepared by: Elizabeth Charlton
Cost Containment & Physician Incentives.
- Among the methods you use to control costs, do you,
directly or indirectly, provide any kind of financial and/or job security incentives (negative or
positive) to any of
your physicians to limit diagnostic tests and referrals to specialists?
- Describe in detail your cost control methods as they affect your physicians
and other medical care providers.
- Do you check the credentials of your physicians?
- Who does the checking for you, and what methods are used?
- Does the check include a history of malpractice lawsuits?
- Can a physician work with your patients before his/her credentials
check is complete?
- How do you define "medically necessary"?
- If there is some disagreement as to what is "medically necessary" for
one of your patients, who in your organization makes the final decision?
- If a specific medical treatment is turned down, is there
an appeal procedure within your organization?
- How long, on the average, does it take to give the patient the final
- Must the patient
initiate the appeal?
5. Choice of
- If a patient in your Plan wants to switch to another
physician in your Plan, can s/he do so?
- How can a patient consult with a physician who is NOT in your
6. Revenue Breakdown.
What percentage of your HMO revenue
- Patient Care? _________%
- Administration and Overhead? __________%
- Payments to Stockholders?
7. Prescription Drugs.
Most HMOs have formularies, which are lists of the
prescription drugs approved for use by their physicians. Physicians are
often pressured to prescribe only the drugs on the formulary, and in some
cases pharmacies are given bonuses to switch a prescription to the cheapest
- Do you offer bonuses to pharmacies to switch
- Are physicians limited to prescribing only the drugs on your
- Formulary drugs can be of three types. Please indicate the percentage
of each type in your formulary:
___________% of your formulary.
- Generic drugs, which
are claimed to be chemically equivalent to the brand names but are usually
less expensive: ___________% of your formulary.
"therapeutic alternatives" which are chemically different from brand-name or generic drugs,
but which are supposed to have similar therapeutic effect: __________% of
Sometimes, for a variety of reasons, the generic and
"therapeutic alternative" drugs are less medically effective, and may
therefore be dangerous to the patient.
- If a physician in your Plan determines that a given
generic or "therapeutic alternative" drug is not the best drug for a given patient,
is the physician free to prescribe the appropriate brand-name drug, and will
your Plan pay for it?
Access to Specialists.
- What must a patient do to see a specialist in your
- On average, how long does a patient wait to see a specialist?
- Do you regularly conduct patient satisfaction
- Do you survey patients who are leaving or have left your HMO because
of dissatisfaction with the treatment provided?
- Do you give bonuses to individual physicians and other care providers
based on the satisfaction of the patients they have treated?
- If one of your members thinks that s/he has a medical
emergency---and if a prudent lay person would consider that this medical
situation is a true emergency---would your member be able to go to the nearest
emergency room for treatment, even if that ER is not a part of your
- In such a case, would you require authorization from your staff before
treatment could be provided?
- If you have different rules for "emergency care" and "urgent care,"
how do you define the difference between the two? Give examples of
If you're thinking of joining an HMO, or of changing from
one HMO to another, send out "The TEN
COMMANDMENTS for HMOs", plus the above "Questions
to Ask Your HMO". Ask the HMO to respond with answers. If they don't answer, or
if you don't like the answers, DON'T JOIN that HMO. Do the same with another HMO
until you find one that answers your consumer concerns.
PLEASE COPY the "Questions to Ask Your HMO" and "The TEN
COMMANDMENTS for HMOs" and DISTRIBUTE
FREELY. When more people ask good questions and insist
on answers, we'll have better consumer protection for everybody.